Constipation

Constipation: Excerpt from In A Page: Pediatric Signs and Symptoms

Constipation is a common complaint, accounting for 3% of all pediatric office visits. Stool frequency can be variable in infants, who average 4 per day (SD 1.8) at 1 week, 2.2 per day (SD 1.6) at 1 month, and 1.8 per day (SD 1.2) at 1 year. After 4 years of age, 95–99% of healthy children and adults defecate at least three times per week.

Differential Diagnosis

• Functional constipation
  –By far the most common etiology
  –Rome II criteria define chronic functional constipation in infants and young children as at least 2 weeks of scybalous, pebble-like, hard stools for the majority of stools, or firm stools two or fewer times per week
  –Presents with stool-withholding behavior
  –Often due to inadequate fluid/fiber intake

• Drugs: Antacids (with aluminium and calcium), anticholinergics, antidepressants, bismuth, calcium antagonists, cough suppressants, opioid analgesics, phenobarbitol
• Irritable bowel syndrome
• Endocrine disorders
  –Hypercalcemia
  –Hypothyroidism
  –Hyperparathyroidism
  –Pregnancy
  –Reduction of steroid hormones in luteal and follicular phases of menstrual cycle
• Hirschsprung disease
  –1/5,000 births, male to female ratio 4:1
  –94% do not pass meconium within 24 hours of birth
  –61% diagnosed by 12 months of life
• Neurologic disease
  –Myelomeningoce
  –Hypotonia (e.g., Down, myopathies, prune-belly syndrome)
  –Cerebral palsy
• Celiac disease
• Cystic fibrosis
• Inflammatory bowel disease
• Lead toxicity

• Structural abnormalities
  –Anal disorders (imperforate anus, anteriorly displaced anus, perianal fissures, strep infection, anal stenosis)
  –Colonic strictures (primary or secondary)
  –Pelvic masses (sacral teratoma)

• Infectious disease
  –Infantile botulism
  –Chagas disease
• Metabolic disorders
  –Uremia
  –Hypokalemia
  –Amyloid neuropathy
• Ogilvie syndrome

Workup and Diagnosis

• History and physical exam are often diagnostic for functional constipation

• History
  –Age at onset, duration, stool frequency/consistency, pain/bleeding with defecation, abdominal pain, toilet training, fecal soiling, stool-withholding behavior, appetite change, nausea/vomiting, weight loss, attempted treatments, dietary intake of fluid and fiber
  –Medical history: Gestational age, time of meconium passage, existing medical conditions, surgeries, delayed growth and development, sensitivity to cold, coarse hair, medications, association with stress

• Physical exam
  –Vital signs (including growth parameters), abdominal exam for fecal mass, anal inspection (position of anus, soiling, sacral dimple, skin tags, perianal fissures; rectal examination: anal wink, anal tone, presence/consistency of stool, fecal mass, other masses, explosive stool on withdrawal of finger, occult blood), and neurologic examination (tone, strength, cremasteric reflex, DTRs)
• KUB may demonstrate fecal mass in uncooperative patients
• Labs rarely needed, but may include thyroid (TSH, free T4), electrolytes (including Ca⁺⁺, Mg⁺⁺⁺, Ph⁺⁺⁺), lead level, and celiac testing (tissue transglutaminase IgA)
• Rectal biopsy, manometry, or BE for Hirschsprung
• Spinal MRI for sacral anomalies

Treatment

• Functional constipation
  –Parental education and demystification of the process of normal defecation
  –Disimpaction with oral laxatives, senna, magnesium citrate, enemas
  –Maintenance stool softeners for 6–12 months, osmotic agents such as lactulose, polyethylene glycol 3350 (Miralax), mineral oil, milk of magnesia, Mylanta
  –Dietary manipulations: Increase fluid intake and increase dietary fiber (14 g/1,000 cal required)

• Cessation of offending drugs when possible
• Correction of electrolyte disturbance
• Treatment of endocrinologic disease
• Hirschsprung disease is treated by surgical resection of agangliotic segment with subsequent reanastomosis

Book Source Details

• Book Title: In A Page: Pediatric Signs and Symptoms
• Author(s): Jonathan E. Teitelbaum, Kathleen O. Deantonis, Scott Kahan
• Year of Publication: 2007
• Copyright Details: In A Page: Pediatric Signs and Symptoms, Copyright © 2007 Lippincott Williams & Wilkins.

More About Intestinal pseudo-obstruction

• Back to disease: Intestinal pseudo-obstruction: Introduction
• Next Book Extract About Intestinal pseudo-obstruction: CONSTIPATION (Differential Diagnosis in Primary Care)
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Copyright notice for book excerpts: Copyright © 2008 Lippincott Williams & Wilkins. All rights reserved.

More About This Book: Title: In A Page: Pediatric Signs and Symptoms Authors: Jonathan E. Teitelbaum, Kathleen O. Deantonis, Scott Kahan Publisher: Lippincott Williams & Wilkins Copyright: 2007 ISBN: 1-4051-0427-9

 » Next page: CONSTIPATION (Differential Diagnosis in Primary Care)

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